Aspergillosis
Background
- Primary affects lung
- Mold: Hyphae that branches 45°
- Inhalation
Clinical Features
Allergic Bronchopulmonary Aspergillosis (ABPA)
- Hypersensitivity reaction to A fumigatus
- Asthma and cystic fibrosis
- Cough, mucous plugs, bronchial casts, hemoptysis, wheezing
- +/- Allergic fungal sinusitis
Chronic Necrotizing Aspergillosis Pneumonia (CNPA)
- Underlying lung disease (steroid-dependent COPD, alcoholism)
- Subacute pneumonia, resistant to antibiotics and cavitates
- Fever, cough, night sweats, weight loss
Aspergilloma (Fungus ball)
- Preexisting cavitary lung disease (Tb, sarcoidosis) or cystic lesion (PCP)
- Hemoptysis, cough and fever
- Asymptomatic radiographic abnormality
Invasive aspergillosis
- Neutropenia or immunosuppression
- Organ transplantation (bone marrow), leukemia, lymphoma, chemotherapy
- Long-term steroid use (ex COPD)
- Fever, cough, dyspnea, pleuritic chest pain, hemoptysis
- Rapidly progressive, can be fatal
- Can cause skin infection
Differential Diagnosis
Causes of Pneumonia
Bacteria
Viral
- Common
- Influenza
- Respiratory syncytial virus
- Parainfluenza
- Rarer
- Adenovirus
- Metapneumovirus
- Severe acute respiratory syndrome (SARS)
- Middle east respiratory syndrome coronavirus (MERS)
- 2019-nCoV (COVID-19)
- Cause other diseases, but sometimes cause pneumonia
Fungal
- Histoplasmosis
- Coccidioidomycosis
- Blastomycosis
- Pneumocystis jirovecii pneumonia (PCP)
- Sporotrichosis
- Cryptococcosis
- Aspergillosis
- Candidiasis
Parasitic
Evaluation
- ABPA
- Eosinophilia
- Skin test + for A. Fumigatus
- Serum IgE > 1000 IU/dL or > x 2-fold rise from baseline
- Aspergillus precipitins +
- Aspergillus radioallergosorbent assay test + and sputum culture
- CXR: Fleeting pulmonary infiltrates, mucoid impaction, central bronchiectasis
- CT chest: Bronchiectasis, lobulated masses that are mucus-filled dilate bronchi
- Aspergilloma
- Precipitin Ab test +
- CXR/CT: Mass in preexisting cavity, often in upper lobe (crescent of air outlining solid mass)
- Invasive aspergillosis and CNPA
- Visualization of fungi (Silver stain)
- Positive culture from sputum, needle biopsy, or BAL
- Galactomannan level
- CXR: Nodules, cavitary lesions, alveolar infiltrates
- CT chest: Halo sign, screscent of air surrounding nodules, wedge-shaped or pleural-based infiltrates, cavitation, pulmonary infarction
Special Population: Cystic Fibrosis
- Diagnosis: Clinical deterioration; IgE> 1000IU/mL or > 2-4x baseline; + serology; new infiltrate
- Treatment: New radiologic finding and symptoms and change in baseline IgE >500 IU/mL
Management
- Pulmonary consult +/- ID consult
- ABPA: Oral corticosteroids
- Recurrent chronic, add oral itraconazole +/- surgical resection of nasal polyp
- Aspergilloma
- Symptomatic (hemoptysis): Oral itraconazole
- Intracavitary CT-guided percutaneous catheter px for amphotericin B
- Surgical resection
- Bronchial artery embolization
- Invasive aspergillosis
- Voriconazole DOC
- Alternative: Posaconazole, amphotericin B, caspofungin
- Reduce immunosuppression
- CNPA
- Voriconazole, itraconazole, caspofungin, or amphotericin b
- Reduce immunosuppression
Disposition
- Invasive aspergillosis often requires admission
- Admit if massive hemoptysis
- ABPA usually managed outpatient
See Also
External Links
References
- Harman EM, et al. (2014, May 31). Aspergillosis. eMedicine. Retrieved 12/24/2014 from http://emedicine.medscape.com/article/296052-overview